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Infections with methicillin resistant Staphylococcus aureus (MRSA) usually occur in individuals with well established risk factors such as a recent hospital admission, multiple antibiotic treatment, or chronic illness. We report on repeated ocular presentations of preseptal community acquired MRSA cellulitis in a previously healthy 20 year old male student.
A 20 year old student presented to the eye department with a five day history of left periorbital swelling associated with a crusted lesion on the temporal border of his left eyebrow and preseptal cellulitis. Past medical history was remarkable for the appearance of similar skin lesions six weeks previously on the right calf, and mild eczema. Similar lesions were found on the patient's neck, back, and right calf. The latter lesion was discharging and swabbed for culture and sensitivities (fig 11).). Initial treatment with oral flucloxacillin failed to resolve the cellulitis and he was admitted 36 hours later. Examination revealed a tense swelling of his left upper lid, with periorbital erythema and oedema (fig 22).). Formal Snellen visual acuity was 6/5. There were no post‐septal signs. The patient was apyrexial and had a moderate neutrophil leucocytosis. He was started on intravenous benzyl penicillin and flucloxacillin with little clinical improvement. Two days after admission, conjunctival and calf swabs cultured MRSA, resistant only to fucidic acid and flucloxacillin, suggestive of a community acquired (CAMRSA) strain. He volunteered that a member of his football team had similar skin lesions six weeks earlier, which settled spontaneously. Treatment was changed to oral linezolid and vancomycin eye drops. The periorbital erythema, oedema, and conjunctival injection improved gradually over the next three days. After two weeks of inpatient antibiotic treatment the patient was discharged on a further one week course of oral linezolid.
The patient re‐presented with identical symptoms on two separate occasions one week after conclusion of the initial course, and again six weeks later. Nasal, groin, and conjunctival swabs from the left eye grew the same strain of community acquired MRSA. He was put on a 14 day course of vancomycin eye drops, oral linezolid, and oral rifampicin, again with a rapid clinical response. He also underwent an MRSA decolonisation regimen and dermatological evaluation of his eczema, with subsequent emollient treatment. His family members had no history of skin infections and were swabbed to investigate the recurrent nature of this infection but none was found to carry MRSA. Subsequent screening swabs from the patient have been negative to date.
Infections with MRSA tend to affect individuals with established risk factors and the involved strains have typical sensitivities. The MRSA isolate from this patient was resistant to flucloxacillin and fucidic acid but sensitive to ciprofloxacin and erythromycin. This unusual sensitivity pattern is similar to those of previously published Irish non‐ophthalmic CAMRSA.1 The atypical sensitivities and the history suggested a CAMRSA infection, so specimens were sent to the National MRSA Reference Laboratory for further testing. Polymerase chain reaction for the Panton‐Valentine leukocidin cytotoxin gene commonly found in CAMRSA was positive. The antibiogram‐resistogram type (AR) was unfamiliar, but similar to multilocus sequence (MLST) 80, which is the most commonly found genotype of CAMRSA in Europe.
CAMRSA with ophthalmic manifestations is rare. Rutar reported ophthalmic sequelae consisting of orbital cellulitis, endogenous endophthalmitis, panophthalmitis, lid abscesses, and septic venous thrombosis in a North American population with no evidence of recurrent disease.2 Known risk factors for transmission of CAMRSA include end stage renal disease, recent hospital admission, an outpatient visit, nursing home admission, antibiotic exposure, chronic illness, and close contact with a person with risk factors including health care contacts.3 Our patient did not have any of these, but did have contact with a fellow football player with similar pustular skin lesions.
Kazakova et al reported an outbreak of CAMRSA among professional football players.4 Infection was associated with turf abrasion sites and a high body mass index. Huijsdens reported an outbreak of ST80 CAMRSA infection in members of a Dutch soccer team.5 The recurrent nature of sport associated CAMRSA has also been documented previously.4,5 Management of this patient's eczema may have been an important factor in the prevention of subsequent infections. Physical contact with infectious lesions, skin damage that facilitates bacterial entry, and sharing of infected equipment, clothing, or personal items may all result in the transmission of MRSA infection in athletes. Our patient fits into this group.
To our knowledge this is the first report of a European patient with an ocular manifestation of CAMRSA from a population of young healthy athletes with no established risk factors. Physicians must be aware of the increasing incidence of CAMRSA infections and the new clinical challenges these cases will present.
We thank Dr Angela Rossney, National MRSA Reference Laboratory, for typing the MRSA strain.
Informed consent was obtained for publication of figures 1 and 2.
Competing interests: None declared.